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*' -tV4tq 04W <br /> 3 j4//t <br /> Dispenser Conversion Evaluation Form <br /> Distributor: Sales Person: P.O. <br /> OW <br /> Existing Dispenser <br /> FMANU, FACTURER D999 Y� <br /> SP C <br /> SPECIFIC MODEL NUMBER Vtrr,,� S <br /> NEW Dispenser <br /> MANUFACTURER P a I�s9lZ Wt <br /> SPECIFIC MODEL NUMBER <br /> Ot/ Tlvr� si <br /> ing <br /> DISPENSER I WYDRAUUC CABINET <br /> ExistUDC Sump <br /> 1 2 <br /> Is it a Bravo UDC? ® or Make/Model J `� <br /> Shallow pan or Deep Sump? TT— <br /> Water splash lip opening (I.D.): Length Width <br /> #of existing Anchor Bolts for concrete pad/island: <br /> Does the existing UDC have a water splash lip? <br /> FBI TNE SM OF CALIFORNIA - PORCNASE OF ADDITIONAL COMPONERM WIN BE REGUIRED <br /> &=' Does conduit exist within 2" of the inner opening? (IF YES, IMAGES ARE REQUIRED) <br /> 1 <br /> ._J <br /> Does conduit exist outside of the UDC water splash lip? &j2 _ (IF YES,IMAGES ARE REQUIRED) <br /> 8_J <br /> FOR ASSISTANCE, CALL <br /> 800-AT-BRAVO <br /> BRAVO <br /> FAX TO 323-888-4123 OR EMAILLREPRESENTATIVE <br /> 14A <br /> BRkVO .SBRAVO.COM made Cera ied ^^ <br /> lap (��! <br /> PROBLEM B®LVE® 800-AT-BRAVO In E M <br />